Inside Health

Regimen Benefits Children With Cerebral Palsy

By SANDRA BLAKESLEE

Published: February 3, 2004

A small study has found that babies and children with certain kinds of cerebral palsy can learn to use their neglected arms by following an intensive form of therapy developed for adult stroke victims.

The regimen, called constraint-induced movement therapy, involves putting the child's good arm into a cast for three weeks and having the child work with a therapist, one on one, six hours a day six days a week to practice movements using the bad arm. The practice, called shaping, challenges the child to improve performance a little at a time.

Dr. Edward Taub, a psychology professor at the University of Alabama at Birmingham, who developed the therapy for stroke patients, led the new study. It appears in this month's issue of Pediatrics.

This is the first systematic work to test whether the therapy works in certain brain-damaged children, said Dr. Bernard Z. Karmel, a developmental psychologist at New York's Institute for Basic Research in Developmental Disabilities on Staten Island, who was not involved in the research. The work shows that the brain can reorganize when the children receive intense therapy, he said. For that, he added, ''Ed Taub deserves a lot of credit.''

Cerebral palsy is a catch-all term to describe difficulties in moving various parts of the body caused by problems in the developing brain. One case in five is caused by stroke around the time of birth. Lack of oxygen to the brain, low birth weight due to multiple births after in vitro fertilization and maternal infection, including benign conditions like periodontal disease, have been linked to cerebral palsy.

Constraint-induced therapy for adults is based on the idea that after a stroke, many cells near the main site of injury are stunned. People try to move their limbs but nothing happens. After a while they give up. Learned helplessness sets in. But by restraining the good limb and practicing movements with the bad limb, patients can overcome learned non-use, Dr. Taub said.

The situation with children is different. Normal limb movements never develop, and so the children are not trying to regain something that has been lost, Dr. Taub said. Their problem is called ''developmental disregard.''

The study involved 18 children who suffered perinatal strokes. The youngest was 7 months, the oldest 8 years old. The younger children crawled using only one side of the body and always pushed themselves up with the good arm. The older children let their bad arms dangle.

Randomly put into two groups, half the children received conventional cerebral palsy therapy. They worked with a therapist for 2.2 hours a week practicing movements, like trying to lift their arms over their heads.

The others received constraint-induced therapy. Their good arms were fit with lightweight fiberglass casts, then they worked with a therapist on shaping movements for their bad arms. This involved lots of play, Dr. Taub said. The children picked up puzzle pieces, broke soap bubbles with their fingers and pounded balls into holes with a plastic hammer. Each time the children showed new movements, they were heaped with praise and the therapist then ''shaped'' the skill by asking for more precision, fluidity of motion or ability to respond automatically.

The children practiced everyday tasks like dressing, eating, bathing and grooming. They chose things they were interested in. When a child began to lose interest or show fatigue, Dr. Taub said, the therapist might slow down but would not stop the activity.

On objective scales, the children receiving intense therapy learned an average of nine new motor patterns compared with two in the control group. One 18-month-old began crawling up steps and putting food in his mouth with his formerly neglected hand. A 4-year-old who had never used his bad arm can now play baseball, batting with both hands and using a specially adapted glove on his more impaired hand.

Several studies have placed casts on children and let them loose, so to speak, to practice normal movements on their own, using their bad arms. The children showed small improvements, like grasping a little better, but there was no indication that the benefits translated into meaningful movements, Dr. Taub said.

The intensity of training and the internal rewards associated with shaping appear to be the major factors in making the therapy work for children, Dr. Taub said. But how children make such improvements in just three weeks is still a mystery, he said.